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General NPI Number Information
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NPI Number | 1982107140
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Entity Type | Organization
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Legal Business Name | ELAN VITALE HEALTHY LIVING SOLUTIONS
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Dates
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Enumeration Date | 03/14/2018
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Last Update Date | 03/14/2018
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Provider Practice Location Address
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Address Line | 27247 JOY RD
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City | DEARBORN HTS
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State | MI
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Zip | 48127-1022
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Country | US
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Telephone | 248-667-6307
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Fax |
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Provider Business Mailing Address
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Address Line | 27247 JOY RD
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City | DEARBORN HTS
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State | MI
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Zip | 48127-1022
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | JACKIE DUNCAN
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Credential | PMHNP
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Telephone | 248-667-2531
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 4704170920
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License Number State | MI
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